Form 5210/09 Reps and Certs for Experts and Legal Support Services Pr

OMB Number: 3064-0122
Expiration Date: 01/31/2023

Federal Deposit Insurance Corporation

REPRESENTATIONS AND CERTIFICATIONS
FOR EXPERTS AND LEGAL SUPPORT SERVICES PROVIDER
PRIVACY ACT STATEMENT
The FDIC is authorized to request this information from you by 12 U.S.C §§ 1819, 1820, 1822(f); Executive Order 9397 as amended;
and 12 C.F.R. Part 366. The information collected will be primarily used to determine whether you meet the required fitness and
integrity standards to provide expert or other legal support services to the FDIC. Furnishing the requested information is voluntary, but
failure to provide the requested information in whole or in part may delay or prohibit any further consideration of you to provide expert
or other legal support services to the FDIC. The information you provide may be provided to appropriate Federal, state, local or foreign
agencies and law enforcement authorities; to a court, administrative tribunal, or a party in litigation; and to contractors, agents and
other third parties as authorized by law and in accordance with any of the other routine uses described in the FDIC Financial
Information Management Records (FDIC 30-64-0012) System of Records available at www.fdic.gov/about/privacy/. If you have
questions or concerns about the collection or use of the information, you may contact the FDIC's Chief Privacy Officer at
Privacy@fdic.gov.

PAPERWORK REDUCTION ACT NOTICE
Public reporting burden for this collection of information is estimated to average 1.0 hour per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden to the Public Reporting Act Clearance Officer, Legal Division, Room 3082, Federal Deposit Insurance
Corporation, 550 17th Street, N.W., Washington, D.C. 20429, and the Office of Management and Budget, Paperwork Reduction
Project (3064-01220, Washington, D.C. 20503. An agency may not conduct or sponsor, and a person is not required to respond to, a
collection of information unless it displays a currently valid OMB control number.

Page down to access form 5210/09

FDIC 5210/09 (5-21)

Page of

OMB Number: 3064-0122
Expiration Date: 01/31/2023

Federal Deposit Insurance Corporation

REPRESENTATIONS AND CERTIFICATIONS
FOR EXPERTS AND LEGAL SUPPORT SERVICES (LSS) PROVIDER
INSTRUCTIONS: If your response is "Yes" to any of the questions in Section I or II, provide a detailed explanation in the provided
space. Refer to 12 C.F.R. Part 366 for the definition of terms.
SECTION I - DISQUALIFYING CONDITIONS/CONFLICTS OF INTEREST
Among the contractor, any management officials, or affiliated business entities of the contractor, or any employees, agents or
subcontractors of the contractor who will perform services under a proposed or existing contract with the FDIC:
1. Have any been convicted of a felony?

Yes

No

Explain

2. Have any been removed or prohibited from participating in the affairs of any insured depository institution pursuant to any final
enforcement action by the Office of the Comptroller of the Currency, the Office of Thrift Supervision, the Board of Governs of the
Yes
No
Federal Reserve System, the FDIC, or successors?
Explain

3. Have any demonstrated a pattern or practice of defalcation regarding obligations?

Yes

No

4. Have any caused a substantial loss ($50,000 or more) to federal deposit insurance funds?

Yes

Explain

No

Explain

5. Do any have any personal or business, or financial interest or relationship which would cause a reasonable individual with
knowledge of the relevant facts to question their integrity or impartiality?
Yes
No
Explain

FDIC 5210/09 (5-21)

Page of

OMB Number: 3064-0122
Expiration Date: 01/31/2023

6. Are any an adverse party to the FDIC, RTC, FSLIC, or their successors in a lawsuit?

Yes

No

Explain

7. Have any ever been suspended, excluded, or debarred from contracting with a federal entity?

Yes

No

Explain

8. Have any ever had a contract with the FDIC, RTC, FSLIC, or their successors rescinded or terminated prior to the contractor's
completion involving issues of conflicts of interest or ethical responsibilities?
Yes
No
Explain

SECTION II - DEFAULTS
9. Has the contractor or any company under the contractor's control defaulted on a material obligation during the ten (10) years
Yes
No
preceding this submission?
Explain

SECTION III - EMPLOYEES, AGENTS, AND SUBCONTRACTORS
10. Does the contractor agree that it will prohibit any employee, agent, or subcontractor from performing services under the contract
until the contractor verifies that the employee, agent, or subcontractor, to the best of that person's knowledge, would answer "No"
to the questions above?
Yes
No
Explain

SECTION IV - EXPERT/LSS PROVIDER CERTIFICATION
NOTICE: The individual signing this application represents and warrants that he/she has authority to execute this application on
behalf of the contractor, certifies that all of the representations and certifications contained herein are complete and accurate, and is
aware of the penalty prescribed in 18 U.S.C. §1001 for making false statements.
11. Name

14. Signature
FDIC 5210/09 (5-21)

12. Title

13. Name of Firm

15. Date
Page of